Author: Krishan B Kumar
Meninges, i.e. thin layers/membranes (3 in number, named from
outside to inside, (i) the dura mater, (ii) the arachnoid mater
and (iii) the pia mater) covering the brain may also be involved
as a result of tuberculosis, and the disease is called
tuberculous meningitis. In this case, the infection spreads from
the brain to the meninges. Initially, a slow-growing tuberculous
lesion called 'tuberculoma' develops in the brain, adjacent to
the meninges, which ruptures in the subarachnoid space, i.e.,
the space between the second and third layer/meninx, causing
infection of the meninges, leading to the signs and symptoms of
tuberculous meningitis.
It was sometimes thought that there is a true entry of the
tubercle bacilli from this 'tuberculoma' into the subarachnoid
space. The author discussed this aspect in detail with related
case reports, with Dr. William Boyd (Canada), a renowned
pathologist, who has also written Text Book of Pathology as well
as Pathology for the Physician. In one of his communications to
the author, while finally approving that there is indeed a
rupture of tuberculoma into the subarachnoid space, he wrote,
"Needless to say, I was most interested in your case of focal
epilepsy followed by tuberculous meningitis. It seems to me that
your idea of a tuberculoma rupturing and discharging bacilli
into the subarachnoid space is the most reasonable one". In the
case of the patient, discussed with Dr. Boyd, the patient
developed focal epilepsy as a result of tuberculoma in the
brain, and thus primarily presented the signs and symptoms of
epilepsy, and later, as a case of tuberculous meningitis after
the probable rupture of tuberculoma into the subarachnoid space.
An early diagnosis and treatment of tuberculous meningitis is
most important in order to save the patient from various
neurological deficits. It should be treated as a medical
emergency. A delay in treatment could result in permanent
disabilities. Initially, the patient gets vague symptoms like
malaise, loss of appetite, a vague headache, irritability, and
soon he gets the so-called symptoms and signs of meningial
irritation, as a result of the tuberculous infection of the
meninges, like a persistent headache, vomiting, neck rigidity /
stiffness, etc. Stiffness of the neck is a valuable sign of this
disease, and the rigidity of the neck gives the clinical clue to
the diagnosis of tuberculous meningitis. Another important sign
is that the patient cannot extend the leg after the thigh has
been flexed, or brought close to the abdomen (called Kernig's
sign). Of course, this is usually elicited by the physicianl
neurologist while examining the case in detail.
It is important to recognize all the early signs and symptoms
of tuberculous meningitis before the disease advances. All the
relevant tests must be carried out to locate the lesion of
tuberculosis in other parts of the body, especially in the
lungs. An examination of the cerebrospinal fluid (CSF),
including the computed tomographic (CT) scanning of the head, is
also required for the diagnosis of tuberculous meningitis. Once
diagnosed, the patient should be immediately put on suitable
antituberculosis treatment in proper dosages, for a suitable
period, so as to eradicate the infection of tuberculosis from
the brain.
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